A man of mature age, well educated, well built and in every respect in good health, without nervous history and without other nervous symptoms, suffered vehemently by the persistent recurrence of a visual image which entirely absorbed his attention. He knew exactly the development of his trouble. A woman acquaintance of his had committed suicide by poisoning herself. He knew her slightly and the emotion of personal loss played hardly any rôle in the case. But he had met her at a gay dinner a short time before her death. The news of the suicide came to him when he was overtired from work. The idea of the contrast between seeing his friend partaking of the dinner and imagining her drinking the poison gave him a strong shock. There was hardly any grief mixed in. He remembers that he shivered at the thought of the contrast, and in that moment the visual image of the woman raising a glass of poison to her mouth flashed into his mind and thus became almost a part of the shock. From that time on, the memory image of this scene returned more and more frequently. At first it associated itself with any chance mentioning of death or suicide and to a very slight degree with the idea of a meal. More and more any element of a meal and of social life, the word soup or meat, the word gown or dance, brought up at once the picture of the woman, which had in the meantime lost every element of personal relation. Any sad thought of her ending had faded away. It remained merely a troublesome impression. The man fought against it by trying to suppress the idea but the more he fought against it, the more insistently it rushed forward through new and ever new association paths. Any advertisement in the newspaper referring to food, anything in a shop window referring to ladies' dresses, any household utensils related to a meal, and especially the meals themselves, forced the visual image into the centre and captured the attention to such a degree that a confusing distraction from the real surroundings resulted. The struggle against the idea became more and more exasperating, made life a torture, almost suggested despair, even faint thoughts of suicide, and especially a growing fear that it was a symptom of the beginning of insanity.

When he came to me, a number of physical cures, especially bromides and electricity, had been tried in vain by the physician. Some weeks in the country had not changed the distress. He came to me with the direct request as a last resort to try hypnotic treatment. I found in spite of the fact that he and his physician had constantly spoken of visual hallucinations that the visual image had no hallucinatory character at all, that is, he never believed that he saw the image of that woman as if it were actually present, he never took the product of his imagination for reality, nor had it the vividness and character of reality. It was hardly more vivid than any landscape which he tried to remember, only that it controlled the interplay of ideas in such a persistent way. I found that he was a strong visualizer and easily suggestible. I told him beforehand that I should hypnotize him only to a slight degree, that he would not lose consciousness, that he would remember everything which I told him. Then I asked him to lie down and had him gaze on a crystal only for half a minute, then close the eyes. I asked him to relax and to think of sleep. With the two blunt points of a compass, I touched his two cheeks at corresponding places, then his forehead. And now I told him that I would begin with the hypnotic influence. I put my hand on his forehead and spoke to him in a monotonous way, saying that he felt a fatigue in his shoulders, and in his arms, creeping over his whole body and assured him that he was now fully hypnotized. To what degree he really was hypnotized cannot be said as no effort was made to test it by any experiments, thus avoiding any possible reaction against the feeling of submission. Expression and breathing indicated a slight hypnoid state. Then I removed my hand and spoke to him in a warm and assuring way.

I told him that in future he would give his full attention to his meal, and not give the slightest attention to any image of his friend. If he should think of the friend the memory would appear indifferent, he would not even notice the image and would give his whole mind to the objects with which he was engaged. In the same way, when he should be reading newspapers or looking in shopwindows, his whole attention would belong to that which he really perceived. Any passing inner image would be ignored. Then I awoke him from his sleep. He was unwilling to believe that he had been in hypnosis at all. I told him that the effect would prove it and in his fully wakeful state I explained to him why there was not the slightest fear of insanity justified, that it was a psychasthenic state resulting from fatigue and shock and from a wrong attitude of his attention during the past months, and then I asked him to return the next day. Intentionally I had not given the suggestion that the image would disappear. I could not expect it would disappear entirely after a first treatment and even a faint appearance of it would have at once fascinated the attention and brought about the whole disturbance of the equilibrium which might become habitual. Instead of it I gave the impulse to the counter-idea, that is, I reënforced the attention towards that which he really saw around him and thus withdrew the attention from the rival image in the mind. The success was complete. He came the next day in a much happier frame of mind, reporting that he still had seen the image of the woman every few minutes, especially strongly at the breakfast table, but it had no longer troubled him. It was more in the background of consciousness, sometimes it appeared transparent, it no longer held his attention, and he felt free to give his full attention to the actual surroundings.

On that basis I hypnotized him the second day and he had hardly heard me saying that he ought to try to sleep when he was evidently in a much deeper hypnotic state than the first time. Again I suggested only the opposite attitude, the positive turning to the surroundings and the complete neglect and indifference for the possible memory image. This time the effect was still stronger. On the third day he reported that he still saw the image but he no longer minded it, as it was like a veil through which he looked at real objects and that left him entirely indifferent. His mind was hardly engaged with it any more. The real spell of the attention was broken. On the basis of this situation, I took the last step and suggested that the image of the woman would disappear altogether and would not trouble him any more. In the next twenty-four hours, it still returned two or three times, but colorless and faint. The following day I was able to eliminate it altogether. Even when the last trace of the inner struggle between the memory and the perceived surroundings had disappeared, I went on with two hypnotic sittings to give stability to the new equilibrium, to insist that the image would not come back and to settle completely that inner repose with which every fear of possible disease evaporated. I feel sure that the cure would not have been reached so quickly, possibly not at all, if the second suggestion, the disappearance of the image, had been given at the first step. The improvement was secured because the antagonistic process itself was used for the suggestion. On the other hand, there was no doubt that in this case the strong will of the patient or suggestion in a normal state would not alone have been sufficient. The hypnotic treatment was indicated by the symptoms and justified by the results.

The patient is a highly educated physician of middle age. He reports that he had been neurasthenic all his life with slight ever-changing symptoms. He has always been troubled by the "perseveration" of tactual images which had a strong feeling tone and which were associated with seen or heard reports of the experiences of others. For instance, when he read in a newspaper that someone had hurt his hand with a pin, or that someone had cut his foot on a nail, he immediately felt a not directly painful but uncomfortable sensation at the particular place in the hand or in the foot, together with a shrinking of the whole body and such tactual sensation usually returned during the following days in fainter and fainter form until it faded away. Most troublesome had always been the reading of any torture processes in historical books or in fiction. Yet there had never been a case in which the sensations really had the vividness of hallucinations and never a case in which the after effects had not disappeared at least in a few weeks.

This time the effect had already lasted four months and it became more and more troublesome. The patient had not the slightest fear of mental disease and no anxiety, but he felt a very serious disturbance by the instinctive effort to get rid of the intrusion. The place of the disturbance was the wrists. The starting point was a definite experience. On an unusually hot summer day the physician had listened for a long time to the complaints of a female patient who suffered vehemently from a nervous fear of scissors and knives and who was afraid that she would cut her artery at the wrist. He believes that it was the exhausting heat of the day which weakened him to a point where the story of his patient affected him very strongly and made him think of it all the time. Yet there was no sensation element involved. A few hours later, he sat in a hotel at his dinner. Just in front of him a butler started to carve a duck with a long, sharp knife. In that moment he felt as if the knife passed through the wrists of both arms. He felt for a moment almost faint; arms and legs were contracted and an almost painful sensation lingered in the skin, and did not disappear for hours.

From that day at the sight of knives or razors, not only in his hands or his direct neighborhood, but also in a store and finally in a picture, stirred up at once the optical image of that carving knife cutting into the skin of the wrist, only with the difference that it seldom was found in both arms, usually in the one or the other. The sensation became a strictly tactual one with optical overtone, but there was no emotion in it. The pain element had disappeared. Also the shock, which still recurred in the first days slowly disappeared. The longer the symptom lasted, the more the optical factor faded away, and the tactual factor came into the foreground after three or four weeks. Perhaps seeing a razor in a store window or a pocket knife open no longer stirred up the image of cutting the wrist, but simply a strong tactual sensation, as if the skin of the wrist was scratched and pinched. Finally, after about two months, the association character disappeared to a high degree and the scratching and cutting sensation in the skin became independent and automatic. The patient awoke in the morning with a vivid tactual hallucination of being cut without associating with it any picture of a knife. Throughout the day, in the midst of work and in the midst of conversation, sometimes one and sometimes the other wrist became the center of the exasperating sensation, easily bringing with it involuntary reactions as if to withdraw the arm. This became more and more frequent and more and more vivid.

The doctor, fully aware of the borderland character of this experience, felt sure that his inner fight against the disturbance would get control of it. The usual tonics did not show any influence. On the other hand, there were no other nervous symptoms and, with his most acute analysis, he did not find the slightest trace of emotion any longer. When the symptoms reached a point at which they seriously interfered with his comfort, he asked me for psychotherapeutic treatment, under the condition that I was not to apply hypnotism. He was absolutely averse to the use of hypnotism in his own case because he was afraid that to be hypnotized would mean for him a certain disposition to fall into hypnotic sleep by auto-suggestion, as he knew the vividness of his imaginative sensations. He wanted to avoid that the more as his own professional work might sometimes demand hypnotizing in his own practice. In any case he had an aversion to it and asked for other means.

Under these circumstances, it seemed to me the most logical conclusion that the counter idea with its antagonistic reactions might be reënforced by direct perception. The abnormal tactual sensation forced on consciousness the idea of the cutting of the wrist. The necessary counter action would be to force to consciousness the idea of the uninjured wrist and the corresponding reactions. As the wrist can be easily made accessible to sight and as I anticipated that the visual sensations would be more forceful than the tactual ones, I told him to look straight at his own wrists for ten minutes three times a day after waking, after luncheon, and before going to bed. He had to hold his two forearms close in front of his eyes and stare at them, giving his full attention to the visual impression of the smooth, uninjured skin of the wrist. If during this process, the tactual counter-sensations were vivid, he had to go on with the staring at both arms, both held near together until the perception had crowded out the rival touch sensation. When this performance had been carried out six times, he did not notice the coming up of the tactual sensation with vividness any longer. From the third day it had disappeared entirely. I told him to go on with the process still every morning for some weeks. The physician himself considered the cure as complete.

The patient is a school-teacher in the Middle West, a nervous, thin-looking woman of about twenty-five. Her only complaint is a persistent idea that she may at any time get a child. She has had this idea "as long as she can remember," according to her first expression. She never had any intimate acquaintance with any man, she was never engaged, she hated bitterly every thought of immorality, she knows and has assured herself by much reading that it is entirely impossible that she might get a child without sexual contact. Yet this thought recurs to her all the time, even when she is talking with other people. It embarrasses her in school, in spite of her teaching only girls in a private institution. This thought keeps her away from company and the effect of its embarrassing occurrence depresses her, but she is sure that the thought itself does not include any emotion. It is a mere thinking of it with a full consciousness that it is absurd, and yet she cannot suppress it.

I began at once to try to find the origin of her queer obsession. After some efforts to pierce into her memories, we came to an experience of her youth. When she was about thirteen years of age, a young girl whom she had admired much for her beauty, living in the neighborhood of her parents, suddenly got a child which died after a few days. At that time no thought of immorality seems to have entered into that news. It was evidently mere sadness about the quick death of the child which gave to the experience its emotional tone. She was at that time completely naïve. She received an intense shock in the thought that an unmarried girl may suddenly get a child which would then quickly die. She cannot tell whether the thought that she herself would get a child had ever entered her mind before this occurrence in her neighborhood, nor can she say that it occurred immediately or very soon after it. She now knows only that she has always had that thought, but whether that means more than ten years, she does not know.

I considered it a justifiable hypothesis that this strong emotional experience early in life had become the starting point for that secondary absurd thought. I considered that primary experience as cause for a deep physiological brain excitement which had irradiated towards the ideas of her personality. It had stirred up there associations which kept their psychological character while the primary disturbance had long lost its psychical accompaniment. It worked its mischief in a physiological sphere but was probably still the starting point for the persistent obsession. My aim was to remove this cause. It would have brought little improvement simply to suppress the freak idea as long as that physiological source was active. On the other hand I should not have the means to stop the physiological after-effects of that real experience: I had to sidetrack it and to secure thus a reduction. I decided therefore to work on the basis of that hypothesis, to accept that physiological complex as existing, but to switch it off by linking it with appropriate associations, thus setting it right in the whole system of her thoughts.

For that purpose I brought her into a hypnoid state, bending her head backwards and speaking to her with slow voice until I saw that a slight drowsy state was reached. In this state I asked her to think back as vividly as she could of that experience of her youth, to fancy herself meeting that pretty girl, her neighbor, once more. She is to imagine that she speaks with her. Now I make her talk with me and she assures me that she sees the scene distinctly. She believes she sees the girl on the street. I ask her to tell the girl how indignant she feels over her behavior; she is to tell her that she understands now all which she did not understand in her childhood, that she knows now that she must have lived an immoral life; that she must have had a friend and that a pure girl like herself could never under any circumstances come into such a situation, that no pure girl could suddenly have a child. She is to express to the other girl her deepest disapproval of such conduct and her own feeling of happiness that anything like that could never happen to her. In accordance with my demands, she worked herself entirely into the scene: without using audible voice, she internally spoke with great vividness to her neighbor. When I awoke her from her drowsy state, she was quite exhausted from the excitement. I repeated that scene with her four times. She assured me that she felt it every time more dramatically. The power of the obsession weakened from the first day. After the fourth time, it had disappeared. The subcortical complex had evidently found its normal channels of discharge.

The patient who lived with his family in Seattle wrote to me the following: "——I shall undertake to describe in a few words a condition which the writer has fought against for about eight years and which has subjected him to untold mental anguish.——I was backward in a social way but altogether happy. After working in a bank about a year, was discovered one evening by the cashier smoking a cigar in the basement, was unable to look him in the face at the time. Went home that night and thought very little about it, but on the following morning during the regular course of business, I stepped up to him to ask some question, and as usual, unconsciously looked him in the face. His glance was questioning and suspicious, and that was the beginning of a life of anguish for me. At first I could not look him in the eyes, then when looking at some other person, I happened to think of it and so on, until in two or three days it was impossible to look at anyone who came to my window. The cashier did everything he could for me. No use: I quit my position, lost most of my friends, had to leave a happy home and came to Seattle to work for an old school friend. In the first year, owing to new environments, I managed to conceal my mental condition to a certain degree. All of a sudden, I was again plunged into the depths of black despair. It took me about two years to (partially) forget it, when the same thing occurred again, and I lost my grip. The last time about eighteen months ago was almost more than I could stand. These three or four instances I speak of were cases of extreme despondency, but my usual mental condition is extremely unhappy. If occasions arise where I have to sit and talk to anyone for ten minutes, controlling myself is such an effort that it leaves me with a case of the blues.... I shall come and see you as the relief would give me a new lease on life."

This letter was written on the twenty-third of January, 1908. I replied to him at once that he certainly ought not to come from the Pacific to the Atlantic, but that I wanted him to write to me much more about that first occurrence. As he was evidently right in considering that episode as the starting point of his troublesome associations, I supposed that these associated ideas had not yet become independent but were still the effect of that first "complex." Therefore I wanted to bring that to complete discharge. Accordingly I wrote him to think himself once more into that happening of years ago, to pass through it with all the power of his imagination, to describe it to me then in as full a statement as possible and to express in the letter also his conviction that there was no reason to avoid the eyes of his superior, that he might have looked straight into his face. As soon as he got my reply, he wrote to me on the sixth of February a description of that first episode, filling nineteen pages, telling me all about his relations to those various men and every minute detail was brought clearly to consciousness again. I did not add anything further, but the expected occurred. On the eighteenth of February, he writes to me: "In the last week or ten days, the writer has noted a decided improvement regarding mental condition. The result is a new interest in life. If you can spare the time, would like to have you write me a few lines. Gratefully yours." At the end of the month he writes: "Received your letter about half an hour ago. Hasten to assure you with a great deal of pleasure that I am feeling much better. Since sending you the letter regarding the first case, I have noticed day by day an improvement." On the eighth of March: "Since writing you last I have noticed a gradual improvement. It has given me wonderful encouragement." On the tenth of March: "Just a line to say that I am still improving." On the twelfth of April: "I desire to say that since the taking up of treatment with you, life has had a far different appearance to me than it has had for the last ten years." On the twenty-first of April: "Since my first letter to you, there has been such an improvement that I have accepted a position which carries with it much responsibility."

The writer is a young woman of twenty-four, whom I did not know personally. She wrote to me as follows: "I am a writer by profession and during the last year and a half have been connected with a leading magazine. In my work, I was constantly associated with one man, the managing editor. This man exerted a very peculiar influence over me. With everyone else connected with the magazine, I was my natural self and at ease, but the minute this man came into the room, I became an entirely different person, timid, nervous, and awkward, always placing myself and my work in a bad light. But under this man's influence, I did a great deal of literary work, my own and his too. I felt that he willed me to do it. The effect of this influence was that I suffered constantly from deep fits of depression almost amounting to melancholia. This lasted until last fall, when I felt that I should lose my mind if I stayed under his influence any longer. So I resigned my position and broke away. Then I felt like a person who, having a drug to stimulate him to do a certain amount of work, has that drug suddenly taken away, and without it I am unable to write at all...." I wrote to the young lady that she could cure herself without hypnotism and without my personal participation. I urged her simply to speak to herself early in the morning and especially in the evening before going to sleep, and to say to herself that the man had never helped her at her work, but that she did it entirely of her own power, and that he had never had any influence on it, and that she can write splendidly since she has left the place, and much better than before. A few months later, she came to Cambridge and thanked me for the complete success which the auto-suggestive treatment had secured. She was completely herself again and was fully successful in filling a literary position in which she had to write the editorials, the book reviews, the dramatic criticisms, and the social news. As a matter of course, such treatment had removed only the symptom. The over-suggestible constitution had not been and could not be changed. Thus it was not surprising that in the meantime, while her full literary strength had come back, she had developed some entirely different symptoms of bodily character which I had to remove by hypnotism.

The patient, a man of middle age, highly educated, for years had heard voices calling his name. A man with whom he had some personal quarrel, had, as he believed, hypnotized him from a distance and made him act queerly or do things which he really did not want to do, by telepathic influence. It is a development which is found quite frequently. Abnormal organic sensations or abnormal impulses and inhibitions which the patient cannot account for by his own motives become connected with some vague ideas which are in the air, like wireless telegraphy or telepathy or hypnotism from a distance or electrical influence, or magnetism or telephoning, these then attached to an acquaintance who stands in a certain emotional relation. Here, too, some organic sensations evidently had been the starting point and the idea of the man with whom he quarreled had been secondarily attached. From this starting point more and more detail was reached. Every action was brought into connection with the powerful enemy who controlled more and more even the normal and reasonable doings of the patient. My first impression was decidedly that of a paranoiac. Yet in some ways the case suggested another view. There had remained an insight into the unreality of the obsession. The patient did not really believe the theory of the telepathic hypnotic influence. He felt it more as an idea which he could not get rid of and he did not know clearly himself whether he requested hypnotic treatment on my part for the purpose of counteracting the hypnotic power of his enemy or for the purpose of liberating him from his exasperating fixed idea. Moreover, I found that his voices had no hallucinatory character, but were merely sound images. I decided to make the experiment without great hope of success.

I hypnotized the man deeply and suggested that no one can have power over his actions, that he is the responsible originator of everything that he does and that no one can influence him and that from that hour he would feel free from any telepathic intrigue. The effect of the very insistent and urgently repeated hypnotic suggestion during the first rather long treatment was such a surprisingly good one that I decided to continue the psychotherapeutic cure. I hypnotized him daily for two weeks. The belief in the real wrong doings of an enemy disappeared entirely from the first. It was at once apprehended as a mere obsessing idea in the own mind and this idea itself began to be resolved. It lost its unity; the absurd impulses were still felt but they became less and less connected with the idea of another man, and as soon as they were rightly understood as doings of the own mind, the opposite motives gained in strength. A stronger and stronger appeal to his own power made these motives more and more influential. Slowly the association of the influence of the other man faded away entirely. I intentionally had not given any attention to the pseudo-voices, inasmuch as they had not taken any relation to the ideational delusion. I therefore did not include them in my suggestions, as I consider it wise to confine hypnotic suggestions always to as few points as possible. Yet these voices decreased too. At a certain point in the cure I substituted—to save my own time—an autosuggestive influence, or rather a mixed one, inasmuch as I had him read ten times a day a letter of mine which contained appropriate suggestions. After about six weeks, all the disturbances for which he had sought my advice had disappeared.